Estate Planning Questionnaire

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1 Estate Planning Questionnaire (Compiled by the University of Colorado American Indian Law Clinic) i I. General Information 1. Full name: 2. Nickname, maiden name, or other names used: 3. Marital status: Single Married Divorced Separated Widowed 4. Date of birth: 5. Social Security number: 6. Name of tribe where member: 7. Enrollment Number: 8. Other tribes you have ancestry from: 9. Citizenship: 10. Home telephone number: 11. Work telephone number: 12. Home mailing address: 13. E mail address: 14. Employer: 15. Spouse s full name: 16. Spouse s tribe: 17. Spouse s enrollment number: 18. If your spouse is not an enrolled member of a tribe, is your spouse eligible for membership? If so, which tribe? Estate Planning Questionnaire Page 1 of 7

2 19. If your spouse is not an enrolled member of an Indian tribe, is your spouse a descendant of a person who was an enrolled member of an Indian tribe? If yes, how was your spouse related to the enrolled member? For example, was the enrolled member your spouse s grandparent or parent? 20. Other states previously resided in: 21. Have you made a will, signed a trust, powers of attorney or other estate planning documents before?* 22. Previous marriages? Name of former spouse(s) and how and when the marriages ended: 23. Have you entered into a pre or post nuptial agreement*? 24. Have you ever made gift in excess of $10,000? 25. Do you anticipate receiving an inheritance? Approximate size? 26. Are you a trust beneficiary?* 27. Do you own property in another state? On another reservation? * If you answered yes to any of these questions, please bring a copy of the prior will, nuptial agreement, separation agreement, decree of dissolution, trust agreement, or other applicable document with you to our initial meeting. 28. Living Children: (List all natural children, legally adopted children, children you have guardianship of, or children you consider your own that are not your natural or legally adopted children): (1) Full name: Estate Planning Questionnaire Page 2 of 7

3 (2) Full name: (3) Full name: (4) Full name: 29. List any children who have died. Please include the deceased child s birth date: Estate Planning Questionnaire Page 3 of 7

4 II. Beneficiaries Please list the names of the person, groups of persons, or entities (including charitable organizations) that you would like to benefit from your estate upon your death or upon the death of your surviving spouse. 1. Specific beneficiaries. List the persons or entities to which you wish to make gifts of cash or real property upon your death. 2. Individual Indian Money Account (IIM). What person or people do you wish to name as the beneficiary of your IIM. Alternate(s)? 3. Residuary beneficiaries. List the persons or entities to which you wish to leave the remainder of your estate after specific bequests have been made. Also note what proportions you would like to leave each person. It is very important for you to name someone for this section which includes everything not otherwise specified in your will. III. Assets Please list the description, ownership and value of the following assets owned by you, your spouse or jointly. It is not necessary to provide the exact value of each asset; an approximation or average balance is sufficient. Use additional pages as needed. 1. Real estate a. Primary residence Description Ownership Value b. Allotment Do you have an Individual Trust Interest ( ITI ) Report? No Yes Attached Estate Planning Questionnaire Page 4 of 7

5 c. Property #1 d. Property #1 2. Automobiles a. Car #1 b. Car #2 c. Car #3 3. Boats and other recreational vehicles 4. Other valuable personal property (for example, jewelry and collectibles include location) 5. Checking accounts 6. Savings accounts 7. Pay on death accounts 8. Certificates of deposits, stocks, bonds and other securities (k) or other retirement plans Beneficiaries 10. Medical insurance coverage 11. Life insurance coverage Beneficiaries 12. Long term care insurance TOTAL ASSETS: $ Estate Planning Questionnaire Page 5 of 7

6 IV. Liabilities 1. Real estate mortgage 2. Home equity loan 3. Auto loan 4. Business loan 5. Educational loan 6. Other long term debt 7. Credit card debt 8. Personal loan 9. Other short term debt TOTAL LIABILITIES: $ V. Fiduciaries In the course of your estate planning, you will be required to select fiduciaries, which are individuals or entities entrusted to act on your behalf in some capacity, such as to administer assets of your estate upon your death, to administer trust assets on behalf of beneficiaries, to care for your minor children in the event you are unable to do so. List the names and addresses of the persons whom you have selected for fiduciary positions. Please list the fiduciary s relationship to you. When choosing a fiduciary, please note that it is often appropriate for a surviving spouse to act in such capacity and that you can name more than one person to act as a fiduciary. 1. Personal representative is the person who has broad powers to administer and distribute your property after your death. 2. Alternate personal representative: 3. Guardian is a court approved individual who makes decisions regarding a minor child s support, care, education, health and welfare if you die before your child reaches age 18. Estate Planning Questionnaire Page 6 of 7

7 4. Alternate guardian: 5. Trustee is a person or entity who administers and distributes property held in trust. A trust may be established under your will for a variety of purposes such as for administering property for the benefit of minor children or for tax purposes. 6. Alternate trustee: 7. Agent with financial power of attorney is a person authorized to make financial decisions for you during your life. The power of attorney document can authorize this person to assist you in making those decisions for yourself while you are able or to make those decisions for you in the event that you are incapacitated. 8. Alternate agent with financial power of attorney: 9. Agent with medical power of attorney is a person authorized to make medical and healthcare decisions for you during your life. The medical power of attorney document can authorize this person to assist you in making those decisions for you in the event that you are incapacitated. 10. Alternate agent with medical power of attorney: VI. Funeral and Burial Instructions It is helpful to leave instructions regarding what type of ceremony, memorial service or funeral you would like and where you wish to be buried. List whether you have already made any arrangements with a funeral home or have purchased a burial plot. i This checklist was developed based on the Will Information Form by John C. Sledd, Northwest Justice Project, Native American Unit, Seattle WA and the Estate Planning Questionnaire of the Colorado Probate Practice Manual, authored by Howard E. Parks, William S. Huff Editor. Estate Planning Questionnaire Page 7 of 7

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